The Cost of Keeping Promises: Ponies and Prescriptions for the Nation’s Health Care System

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The inauguration of Donald Trump as the 45th president of the United States launches a new administration and a new era in Washington.

One of the most important elements of the new era is one-party control. We last saw this emerge with the Democrats in January 2009. It lasted only two years.

In those two years, the Democrats managed to push through the Affordable Care Act. The following six years witnessed repeated battles over that legislation, in the courts, in Congress and on the campaign trail.

In Congress, those battles took the form of repeated but ineffectual votes to repeal the act. On the campaign trail, it took the form of promises to make those votes effective.

Which is why health care reform now holds center stage.

Some action is essential, and quickly.

This isn’t because swift action necessarily will improve the health care options and outcomes for Americans, or ease the burden on businesses, or control the rising cost of care.

Swift action is required because it was promised, dramatically and repeatedly, by members of both houses of Congress and by the man who is becoming the 45th president. And not just this election year; every election year since 2010.

If a father uses the promise of a pony to quiet an agitated young daughter, Papa can hope the promise will be forgotten. If (as is more likely) the little princess remembers, Papa can suggest that he was misunderstood (“I said a puppy, not a pony”). If she is not fooled by this slight of word, Papa may be forced to admit that he was less than honest and explain why, despite his promise, that pony cannot be had. The heir to his kingdom may fuss, complain, cry, wail, pout and otherwise punish him briefly for his offense, but the long-term peace of the household probably will not be disturbed.

On the other hand, if every year since the little tike was three, many times a year, Papa promised to get that pony, and then that pony appears for sale, it becomes nearly impossible not to follow through . . . whatever the consequences may be.

Crowd-pleasing promises make effective campaign weapons. Repealing Obamacare is just one such promise wielded by one set of warriors to achieve their political ends.

But promises have consequences. If made, they must be kept. If not kept, they must be explained away, or owned as the political tricks they otherwise must have been.

And a promise this big, made this often, by this many? There’s no explaining it away

There seems to be general agreement that the real goal is “repeal and replace,” but there seems to be very little agreement about what the replacement measure should look like. Which makes “repeal” problematic at best.

But that was the promise. And now it can be done.

A dramatic and unqualified promise can secure great political benefits. Fulfilling that promise, however, may prove to have proportionately greater costs. The prudent politician is wise to consider both the political benefit and the real-world cost of the promises he or she makes.